Self-flip Technique of the TightRope RT Button for Soft-Tissue Anterior Cruciate Ligament Reconstruction  Kengo Harato, M.D., Ph.D., Yasuo Niki, M.D., Ph.D., Takashi Toyoda, M.D., Ph.D., Yusaku Kamata, M.D., Ko Masumoto, M.D., Ph.D., Toshiro Otani, M.D., Ph.D., Yasunori Suda, M.D., Ph.D.  Arthroscopy Techniques  Volume 5, Issue 2, Pages e391-e395 (April 2016) DOI: 10.1016/j.eats.2016.01.022 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Preparation of the graft. The artificial ligament (Leeds-Keio; Xiros) is used for the hybrid technique. For the hybrid technique, free limbs of the graft are whipstitched with No. 1 nonabsorbable sutures (Surgilon; Covidien). Each stitch must pass through each strand of graft collagen, and the suture limbs are wrapped twice around the collagen bundles, creating a self-reinforcing suture noose. Then, the artificial ligament is looped, followed by whipstitches using No. 1 nonabsorbable sutures. Thereafter, we draw the first line in the loop of the TightRope RT (Arthrex) at the same length as the femoral tunnel (black arrow), and draw the second line 7 mm longer than the length of the femoral tunnel as a self-flip line (white arrow). Moreover, the third line is drawn on the graft at the same length as the femoral socket (15 mm) (pink arrow). Arthroscopy Techniques 2016 5, e391-e395DOI: (10.1016/j.eats.2016.01.022) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 The side sutures (blue sutures) are pulled from the lateral side, with the TightRope RT (Arthrex) button being pulled into the femoral socket under direct arthroscopic vision. We confirm the first and second lines in the loop of the TightRope RT through the anterolateral portal. We then stop pulling the TightRope RT button just at the second line (white arrow, self-flip line). Arthroscopy Techniques 2016 5, e391-e395DOI: (10.1016/j.eats.2016.01.022) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 We hold the graft at the tibial end on the anterior side so as not to pull too far. Thereafter, the arthroscope should be removed, and we change the knee position from 90° flexion to full extension. It is necessary to pull the side suture strongly with the surgeon holding the graft at the tibial end. Arthroscopy Techniques 2016 5, e391-e395DOI: (10.1016/j.eats.2016.01.022) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 The side suture (blue suture) is inclined to the medial side with strong pulling of the suture. Then, the surgeon pulls the tibial end of the graft until he or she feels a secure positioning of the TightRope RT (Arthrex) on the lateral side of the femoral cortex. Thereafter, the knee position is changed from full extension to 90° flexion. Arthroscopy Techniques 2016 5, e391-e395DOI: (10.1016/j.eats.2016.01.022) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 We insert the arthroscope again in 90° of knee flexion. We can confirm the first line (black arrow) as the same length of the femoral tunnel through the anterolateral portal and the second line (white arrow, self-flip line). Thereafter, final tensioning of the graft is made by pulling the white loop until the third line on the graft aligned to the exit of the femoral tunnel. Countertraction on the tibial end of the graft is applied during graft final tensioning. Arthroscopy Techniques 2016 5, e391-e395DOI: (10.1016/j.eats.2016.01.022) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 A postoperative radiograph is obtained for each patient to confirm the appropriate positioning of the button. Arthroscopy Techniques 2016 5, e391-e395DOI: (10.1016/j.eats.2016.01.022) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions